[NOVEMBER-2018]

AYUSHMAN BHARAT: SILVER LINING IN HEALTH CARE

When the Government of India announced Ayushman Bharat in the Union Budget
for 2018-19, it signaled its intent to take health promotion and health care to
the centre of the political discourse. However, some critics were skeptical as
to whether a programme of such dimensions could be launched within such a short
time-span. With the launch of both components: the Health & Wellness Centres
(H&WCs) on 14th April and the PM Jan Arogya Yojana (PMJAY) on 23rd September,
the Government has amply demonstrated that the budgetary announcements not only
has a strong political backing, but also sent out a clear signal that there is
growing consensus in the higher echelons of policy making that investing in a
good health system is critical to building a prosperous India. ayushman bharat:
india’s road to universal health coverage

Interpreted in a literal sense, Ayushman Bharat is a promise for long lives
to Indians. In other words, it is about mortality avoidance. But increasing life
expectancies cannot be the only goal, if we also simultaneously cannot guarantee
well being by minimizing morbidity. Our National Health Policy 2017 aptly
articulates out goal as “attaining the highest possible level of health and
well-being for all at ages, through preventive and promotive health care
orientation in all developmental policies, and universal access to good quality
health care services without any financial headship”. Ayushman Bharat, with its
two components- Health & Wellness Centres (H&WCs) and PM Jan Arogya Yojana (PMJAY)-
is an attempt to move from sectoral and segmented approach of health service
delivery to a comprehensive system-based one . It undertakes path breaking
interventions to holistically address health; adopting a continuum of care
approach-addressing prevention, promotion, primary and ambulatory care; as well
as secondary and tertiary care requiring hospitalized treatment.

Present Situation:

In the absence of a strong Government stewardship, the Indian Health System
has evolved almost by default. As a consequence, it exhibits extreme
fragmentation on multiple dimensions- financing, organization and regulation.
This has a major impact on the quality of care as well as overall outcomes of
the Health System. For instance, a whopping 67% share of the overall financing
of our health system is in the from out of pocket Expenditure by the Households,
mostly at the point of care. If we look at the organization of care providers,
95.3% of out private health facilities are small facilities employing less than
five workers. Clearly, in a situation where an overwhelming proportion of health
seeking occurs directly by the households from very small private providers on
paper based prescriptions, it is virtually impossible to monitor or regulate the
quality of such care provision. The Government facilities face a different set
of challenges in ensuring quality of care: huge patient load, lack of
accountability, absenteeism, management gaps and fixed salary based payment
incentives.

The current legal framework for regulation of medical service is under the
Clinical Establishment Act, 2010, Drugs & Cosmetics Act, 1940 and the various
Acts governing the profession such as Medical Council of India and other related
professional councils. The weaknesses in out regulatory framework are well
documented. For instance, The Clinical are well documented. For instance, The
Clinical Establishment Act is yet to be adopted by many of the State
Governments. Even where they have been adopted, implementation remains patchy.
The MCI has been repeatedly hauled up by the Supreme Court as well as the
Parliamentary Standing Committee on health and a legislation to replace MCI by a
National Medical Commission.

What is the likely impact of Ayushman Bharat?

The accountability is further enforced through insistence upon compliance to
empanelment norms in order to be registered as a provider with the respective
NHA/SHA. Since the payers would be carrying out inspections of the health
facilities against standardized checklists both at the empanelment stage and
also during the operations stage, it would provide the necessary impetus to the
provider to plug the gaps between their existing infrastructure, procedures and
human resources and what is required of them by the payer. NHA is now in the
process of developing Standard Treatment Guidelines (STGs). As and when the
adherence to STGs is enforced, facilities will be obliged to follow the standard
operating procedures rather than a free for all approach prevalent now. But the
process of ensuring strict adherence needs to be gradual, so that the compliance
burden on the empaneled providers does not become unmanageable.

It is also quite evident that given the measurement and data challenges that
India faces, the ability of the National and the States government to initiate
the desired policy changes and to take appropriate action to improve quality of
care is severely constrained. This has a serious deleterious effect upon the
overall governance and accountability of the Health System. Another potential
game changing impact of the Ayushman Bharat would be through the establishment
of the Technology Platform and a common IT system to ensure availability of real
time data pertaining to health system of course, subject to privacy constraints.
Enormous amounts of data would now be instantaneously available for analysis to
multiple researchers and enforcement authorities. This would give a serious
boost to the quality movement in our health system, further the use of evidence
in making policy decision and would enable pushing for behavioral change on the
part of the providers.

Conclusion:

Improving the quality of health care at the system level requires a focus on
governance issues, improving public-sector management, building and augmenting
institutional capacities as well as promoting a culture of data-driven approach.
Ayushman Bharat has initiated a number of these steps in the right direction,
but they constitute a small subset of a large number of steps that need to be
taken to drive the quality process in the Indian health care system. This is
just the beginning of a long and an arduous journey